This chapter introduces the core governance mechanisms that form the foundation of regulated midwifery in Canada. It touches on some of the key professional responsibilities associated with being a regulated health profession. Midwives, as health care professionals, must understand both features as they relate to the practice of midwifery in a regulated system. They must also be aware of the regulatory and professional frameworks that form the basis for the practice of midwifery in their jurisdiction and to which they are held accountable. This chapter will present the key elements of this professional framework in Canada as a means to enhance understanding of the responsibilities of midwives as regulated health professionals.

Regulated midwifery is new to the Canadian healthcare system. However, midwifery is considered to be one of the oldest female professions in the world. (1) History reveals that the practice of midwifery has existed in the land we now know as Canada since recorded history. (1–6) For example, the services of midwives were part of Indigenous communities well before the European settlement of Canada. As well, there are ample historical accounts of settlers bringing midwives with them dating back to the earliest days of settlement. (1,7)

8.1 Regulating the Profession of Midwifery

The degree to which midwifery as a profession is organized and regulated within the formal health care system varies widely throughout the world. (8) In Canada, the regulation of professions falls under provincial [territorial] authority for the most part. Section 92 of the Canadian Constitution Act, 1867, assigns to the provinces the authority to make laws in relation to property and civil rights in the province. The Supreme Court of Canada and other courts have interpreted property and civil rights under s. 92 of the Canadian Constitution Act, 1867 to include regulation of professions. (9) A fundamental component of these enabling laws made by provincial and territorial governments is the identification of regulatory authorities/bodies (9) that are responsible for protection of the public through the self-regulation of professions and occupations. (10) For example, the Ontario government’s Regulated Health Professions Act (RHPA) and associated health profession Acts set out the governing framework for the regulated health professions in Ontario, including midwifery. The RHPA is intended to (11):

• Better protect and serve the public interest
• Be a more open and accountable system of self-governance (regulation)
• Provide a more modern framework for the work of health professionals
• Provide consumers with freedom of choice
• Provide mechanisms to improve quality of care

Many argue that the regulation of midwifery and efforts to facilitate the integration of midwifery into health care systems represents a much needed and natural evolution of an ancient role, with inherent advantages for the health of mothers and babies and for midwives.

Those arguing in support of the regulation of midwifery believe that providing a formal framework for the professionalization of midwifery and its subsequent inclusion into the health care system nets distinct advantages, namely:

• Making the services of midwives accessible to a greater number and more diverse client base
• Being able to effect change from within the health care system rather than being on the margins
• Having the services of a midwife be covered by a publicly-funded system
• Achieving a legitimized place in the health care system that will lead to improved health outcomes

The International Confederation of Midwives (ICM) provides a clear opinion on the value of regulated midwifery in stating that, ‘by raising the status of midwives through regulation the standard of maternity care and the health of mothers and babies will be improved.’ (12, p.1) The ICM notes that ‘[r]egulation is a mechanism by which the social contract between the midwifery profession and society is expressed.’ (p.5)

Others suggest that the efforts to professionalize midwifery represent a potential danger to the essence of midwifery as a uniquely responsive woman-centered model of care. The close relationship that often exists between midwives and their clients is viewed as one of the distinctive features of midwifery and potentially the most vulnerable to erosion within an organized system of care. (1,5,13,14)

Moreover, a move to become an ‘elite’ profession with a set of standardized clinical skills has the potential to override the caring aspects of midwifery care – the psychosocial aspects of the role, which are regarded, highly. (13) Midwives have been described as guardians of normal birth. The requirement to conform within a medicalized system with its own framework of medically defined standards and requirements is also source of concern to those who have argued against the regulation and professionalization of midwifery. The pressure to conform to bureaucratic requirements, keep up with new technological developments and maintain a place in an increasingly complex medical hierarchy have also been posed as threats that could co-opt the woman-centered model of care that historically midwives have sought to champion. (1)

In contrast, some have argued that many clients do not seek a deeply personal relationship with their midwife at a highly private time in their lives, rather they desire a health professional who is ‘competent and who can assist them to have a safe and positive birthing experience.’ (3, p.23)

8.2 The Shift to Regulated Midwifery in Canada

Globally, midwives have enjoyed a long history of providing maternity care and are well recognized as key to the provision of care to pregnant families. Despite this history, Canada was slow to recognize the practice of midwifery as a legitimate health profession. In fact, until the early nineties, Canada had the unwelcome distinction of being the only developed country in the world that did not officially recognize midwifery. (7) Thanks to the combined efforts of midwives, their supporters, and families who believed in the value of midwifery care within a publically-funded health care system, the majority of Canadian jurisdictions have now recognized the importance of midwifery and have regulated, integrated, and funded the provision of midwifery services.

In 1993, Ontario became the first province to formally regulate the practice of midwifery as a publicly-funded, integrated health service, which can be seen as a turning point in the history of regulated midwifery in Canada. (5) Other jurisdictions followed Ontario’s lead (Table 8-1), and steady progress has since been made in the regulation of midwifery as an important component of maternity care in Canada.

Achieving official recognition of midwifery as a health-care profession is regarded as a significant victory for Canadian midwives and supporters of midwifery care. (13) The new-found legitimacy has marked a significant shift in the way that midwifery is now practiced in Canada.

8.2.1 The Regulation of Aboriginal Midwives in Canada

Historically, Aboriginal communities across Canada have always had midwives. It has only been in the last hundred years that this practice has been taken away from [those] communities. This occurred for a number of reasons, including colonization and changes in the health care system in Canada. As a result of losing midwifery, many rural and remote Aboriginal communities are currently required to deliver their babies and access care outside of their communities. Despite these changes, there are still some Aboriginal midwives practicing in a variety of settings across Canada. (15)

Aboriginal midwives who wish to become registered apply to the governing body (College) of their province or territory. There is variation however across provinces and territories as relates to the regulation of Aboriginal midwives. Nunavut, British Columbia, Ontario and Quebec each have legislation that provides an exemption from registration for Aboriginal midwives. Some conditions on these exemptions do exist – in Nunavut and British Columbia, the exemption is only available for midwives who practiced Aboriginal midwifery prior to the coming into force of the Act. In Ontario, Aboriginal midwives providing care to persons in Aboriginal communities are exempt from the RHPA. The Ontario Midwifery Act allows Aboriginal midwives who provide traditional midwife services to use the title ‘Aboriginal midwife.’ The Quebec statute allows Aboriginal midwives to practice without being registered members, provided that the nation, group or community has entered into an agreement with the government. (16)

8.3 The Legislative Process

In Canada, the administration and delivery of health care services is the responsibility of each province or territory, guided by the provisions of the Canada Health Act. Provinces and territories are primarily responsible for regulating health care professions such as the practice of midwifery. (17)

Midwifery legislation can be divided into two parts: a statute (sometimes referred to as an ‘act’) and regulations. Each has the force of law but are enacted differently. (18) A midwifery statute is introduced and enacted by a provincial or territorial legislature. The purpose of a statute is to set out the broad principles or rules that govern a particular matter such as the practice of midwifery. Generally, a statute includes a provision that authorizes the development of related regulations.

The purpose of a regulation is to set out the details required to carry out the policy objectives of a statute. For example, a statute may require that all midwives be registered in order to practice. The regulations made under this statute will then describe all the requirements of the registration process.

While not law per se, regulating authorities can supplement regulations with enforceable standards that provide further direction regarding midwifery regulations.

8.4 Key Features of Midwifery Legislation in Canada

While midwifery statutes may differ slightly among Canadian jurisdictions, they possess many common features critical to the effective regulation of midwifery. These features include

• The identification of midwifery as an autonomous health care profession distinct from other health professions such as medicine or nursing
• The recognition of midwives as primary health-care practitioners. In some cases, a midwife may be the first point of entry for a person seeking maternity care services
• Legal protection regarding who can use the title of midwife. Where the title is protected, only those persons who meet the requirements of midwifery legislation can legally call themselves a midwife
• A defined scope of practice that includes providing maternity care to healthy women and their newborns during pregnancy, labour, birth and up to six weeks postpartum
• The authority to establish procedures for monitoring, enforcing and holding midwives accountable for the legislative requirements of regulated midwifery. This includes the authority to receive and investigate complaints against members, to remove the authority to practice from midwives who are found to be in violation of the standards of practice and finally to establish quality assurance processes that enhance client safety and improve the quality of midwifery care.

In some jurisdictions and locations of practice, a midwife’s scope of practice may encompass advanced competencies including management of epidurals, induction and augmentation of labour, and continuing care beyond six weeks postpartum. These latter areas of practice are considered to be advanced competencies that expand the scope of midwifery practice and are of particular importance to the midwife’s role in rural and remote areas of Canada where access to primary care practitioners may be limited. After changes to the midwifery regulation in British Columbia, midwives are now able to acquire advanced competencies in acupuncture and to act as surgical first assistants. (19,20) Midwives who assume tasks that go beyond their regulated scope of practice are required to work in collaboration with other health professionals.

To ensure uniformity and consistency, jurisdictions have collaborated on the development of the Canadian Competencies for Midwives. (21) This process was led by the expertise of the Canadian Midwifery Regulators Council. The Canadian Competencies for Midwives provide the basis for both midwifery education programs offered in Canada and for the Canadian Midwifery Registration Examination (CMRE).

8.5 The Role of Regulations

Regulations provide specific instructions regarding how legislation is to be operationalized and enforced and provide the regulatory body with the authority to set and enforce standards of practice. Midwifery regulations include specific authorities and requirements in areas, such as:

• Requirements and processes for registration and maintaining registration
• Standards of practice
• Prescription of medications, procedures and devices
• Screening and diagnostic tests that can be ordered, received, and interpreted
• Minor surgical and invasive procedures that can be performed

Midwifery regulations in Canada are developed and issued by the cabinets of each provincial/territorial government. Regulations are permanent and cannot be revised or changed without government approval, which can be a cumbersome and time-consuming process. As midwifery practice is constantly evolving, it is imperative that regulating authorities have the power to supplement regulations with standards that provide further direction and detail or clarification regarding particular issues that may arise with respect to the implementation of regulated midwifery. While standards are not law per se, they can be enforced by the regulating body. A comprehensive international overview of midwifery regulation is provided by the ICM’s Global Standards for Midwifery Regulation, 2011. (12)

8.6 Midwifery as a Self-regulating Profession

In Canada, midwifery is a self-regulated profession in which implementation and enforcement of midwifery legislation is delegated to a professional body referred to as a College of Midwives. Such colleges are governed by members of the profession and may include government-appointed public members. Some midwifery regulatory authorities have made public representation a requirement for all college committees. (23)

The primary purpose of any regulatory authority is to protect public safety and well-being. As a self-regulating profession, it is midwives who have the responsibility to ensure that midwifery legislation is rigorously and effectively enforced. Self-regulation (as opposed to government or third party regulation) is often seen as an appropriate mechanism for protecting public safety due to the specific knowledge and skills held by the members of that profession.

In addition to its legislative responsibilities, a regulatory college may also be responsible for developing and enforcing a Code of Ethics, supplementary standards of practice, and policies or guidelines on issues related to midwifery practice.

Additional issues governed by the college include:

• Setting standards regarding who may enter the profession
• Setting requirements for members to remain in the profession
• Setting standards or expectations of practice that are intended to protect the public by ensuring care provided is safe and of a high quality
• Creating processes for holding midwives accountable to the standards of practice
• Determining how members may be disciplined or removed from practice

While there is consistency in the regulatory framework across all jurisdictions, every midwife must be familiar with the specific standards to which they will be held accountable. Each local college/regulatory authority outlines standards and guidelines for midwifery practice in their jurisdiction on their website.

8.7 Fundamental Features of Midwifery Self-regulating Authorities

8.7.1 Codes of Ethics

Each regulatory authority must develop a code of ethics, which are intended to outline the values and principles that its members use as reference points to guide their practice. Broadly speaking, a code of ethics provides a moral context for midwifery practice by describing the values and principles that guide the ethical orientation and behavior of midwives in all aspects of their practice. A code of ethics can provide a foundation for decision-making in difficult situations.

8.7.2 Standards of Practice, Policies and Guidelines

Professional standards of practice describe behaviors and practice expectations that midwives must demonstrate in all aspects of their work including clinical practice, education, administration and research. The standards determine how midwifery practice is assessed and the expectation of practice. Standards of practice provide an important guide for midwives in their practice, thereby supporting consistency in practice and ensure accountability of midwives to their regulatory body and to the public. They allow a greater understanding of role of the midwife by the public by providing an open and clear description of the expectations of care they should expect to receive from midwives as well as standards of professional conduct and accountability for midwives.

Standards of practice should be evidence-based and encompass all aspects of midwifery including specific areas of practice, inter-professional relationships, communication and professional responsibilities. (25–27) They can be loosely grouped into three areas of purpose, and may relate to very specific but different areas of practice (Table 8-2).

8.7.3 Continuing Competence

Regulating authorities establish requirements for continuing competence regarding midwifery skills (e.g. being up-to-date in procedures for neonatal resuscitation, cardiopulmonary resuscitation, emergency skills, electronic fetal monitoring, etc.)

There is an expectation that each midwife to make efforts to ensure that their practice is evidence-based, which entails a commitment to remaining up-to-date on research and changing aspects of clinical practice. Those skills that are considered to be advanced skills will require additional training as well as periodic renewal of competency.

8.8 Regulatory Authority vs. Professional Association

The profession of midwifery in Canada is supported by two distinct bodies, each with its own purpose – the regulatory body and the professional association. As the previous section described, the role of the regulatory body is to regulate the practice of midwifery in the interest of protect public safety. In contrast, the role of the professional association is to serve the interests of the profession. Table 8-3 outlines other key features of each body.

In all jurisdictions where midwifery is regulated, registration with the regulatory authority is mandatory as this provides midwives the authority to practice. It has been noted that there are exemptions for Aboriginal midwives in some jurisdictions. However, membership with the professional association may not be required. As noted above, in some provinces/territories the professional association has the responsibility of negotiating contracts and other aspects of remuneration while in other jurisdictions where midwives are funded via an employment model they are often represented through unions that negotiate on their behalf.

8.9 Professionalism in Midwifery

As members of a self-regulating profession, midwives are expected to maintain professional accountability to themselves, to clients in their care, to colleagues, and to their profession. These expectations of midwives are often defined in the Standards of Practice, the Code of Ethics and the Code of Conduct of their regulatory body, and in the case of students in their Student Handbook or Program Guidelines.

Professionalism could be described as set of practices intended to ensure midwives are respectful, thoughtful care providers, who demonstrate ethical behaviour in all aspects of their practice. The principles of professionalism should underpin the application of all aspects of midwifery practice. Some examples of professionalism are outlined in Table 8-4.

8.10 Professional Boundaries in Midwifery Practice

The close therapeutic relationship that can develop between midwives and their clients can be a strength of the model of midwifery care. The relationship is one based on mutual trust. Midwifery care can be described as partnership where clients bring knowledge of themselves and their bodies and the midwife brings their knowledge and skill regarding pregnancy and birth. (28, p.2) Maintaining professional boundaries with the right balance of trust and intimacy is important to fostering effective client-midwife relationships (Table 8-5) where the needs of clients are paramount and midwives are able to maintain appropriate boundaries within the therapeutic relationship.

8.10.1 Midwifery and Social Media

Midwives and midwifery students must clearly understand social media use and misuse. There are potential benefits and pitfalls associated with use of social media in its many forms as a method of interacting, networking and as a communication tool. However, as a highly accessible virtual public space it has the potential to facilitate even unintentional breaches of client privacy and confidentially. Two aspects to consider when using social media in midwifery practice are:

8.10.1.1 Client Confidentiality

Midwives have a responsibility to maintain the confidentially of all clients’ personal health information in accordance with federal and provincial laws, and the policies and standards set by their regulatory body and workplace (midwifery practice or employer). These laws and policies assure clients that their personal health information cannot be used in any manner without their written permission and their privacy is maintained at all times. This applies to written information (even where client identifiers and details have been removed or altered), photographs and other descriptions of events and/or persons. The legal implications of breaches of confidentiality should be understood along with the knowledge that all means of electronic communication/information can be retrieved and could be used in a court of law. One notable exception is when child abuse is suspected: it is the midwife’s duty to report such cases to appropriate authorities.

8.10.1.2 Professional Integrity

Midwives have an ethical responsibility to avoid engaging in any activity that could undermine their own professional integrity and reputation as well as the honour, dignity and credibility of the profession. Therefore, good judgment should be used by midwives when using social media in their personal life.

8.11 International and National Midwifery Leadership

The focus of this chapter has been on Canadian midwifery, and the specifics of regulation. There is a wealth of information on regulation and standards from which midwives may draw, both internationally, and nationally.

8.11.1 The International Confederation of Midwives (ICM)

The ICM is an accredited non-governmental organization agency that provides leadership in maternity services, globally, and represents and supports midwifery professional associations worldwide. The ICM currently has 121 midwifery associations, which represent 108 countries in every continent of the world. Its current membership exceeds 400,000 midwives. The ICM has a clear vision and mission for maternity care and midwifery worldwide (Table 8-6).

8.11.1.1 The ICM Foundational Pillars

The ICM has identified three foundational pillars – education, regulation, and strong member associations – through which it works to strengthen midwifery worldwide. In the area of education and regulation the ICM, through the work of its standing committees, has developed a number of core documents relating to regulations and standards for midwifery. The use of global standards, competencies, tools and their guidelines ensures that midwives in all countries have effective education, regulation and strong associations. These documents guide midwives associations and their governments to review and improve on the education and regulation of midwives and midwifery, and enable countries to review their midwifery curricula for the production and retention of a quality midwifery workforce. They include:

• ICM Global Standards for Midwifery Education (2013)
  http://internationalmidwives.org/assets/uploads/documents/CoreDocuments/ICM%20Standards%20Guidelines_ammended2013.pdf
• Essential Competencies for Basic Midwifery Practice (2013)
  http://internationalmidwives.org/what-we-do/education-coredocuments/essential-competencies-basic-midwifery-practice/
• ICM Global Standards for Midwifery Regulation (2011)
  http://internationalmidwives.org/assets/uploads/documents/Global%20Standards%20Comptencies%20Tools/English/GLOBAL%20STANDARDS%20FOR%20MIDWIFERY%20REGULATION%20ENG.pdf
• Midwifery Regulation Implementation Toolkit (2014)
  http://internationalmidwives.org/assets/uploads/documents/Global%20Standards%20Comptencies%20Tools/English/ICM_Toolkit_ENG.pdf
• ICM Position Statements (2008 – 2017)
  http://internationalmidwives.org/who-we-are/policy-and-practice/icm-position-statements-general/

The full list of the ICM core documents can be found on the ICM website. In addition to its core documents, the ICM has developed a wide range of position statements, which describe its beliefs and principles and provide guidance for its members. The position statements cover a wide range of topics including those that relate to maternal and newborn health as well as other social and economic issues.

Every three years the ICM sets out a strategic direction, which directs its activities for the triennium following. Each triennium the ICM holds an international congress in a member country. The purpose of the congress is to bring together midwives globally to meet and conduct global business and hold scientific and professional meetings. An additional stated aim is to celebrate midwifery as a profession in all its global diversity.

8.11.2 Canadian Association of Midwives (CAM)

CAM is the national organization representing midwives and the profession of midwifery in Canada. CAM is a member of the ICM. Its mission statement includes a commitment to provide leadership and advocacy for midwifery as a regulated, publically-funded profession. CAM provides leadership in providing a midwifery perspective on issues of national health policy in maternal and child health. All provincial and territorial midwifery associations are eligible to be members of CAM and currently have membership on the CAM board of directors. Individual midwives who are members in good standing of their local midwifery association are eligible for full membership of CAM. Membership is also open to midwifery students.

The objectives and activities of CAM are supported by its mission statement, values and beliefs. The goals and activities of CAM are described in a five-year strategic direction developed by the CAM Board. CAM also has developed a number of position statements that relate to issues of midwifery practice in addition to areas of social and economic interest.

Another important contribution of CAM to Canadian midwifery is the establishment of the Canadian Journal of Midwifery Research & Practice. As the official journal of CAM, it is Canada’s only national, peer-reviewed midwifery journal. (30)

Each year CAM hosts a national meeting and conference in a member province/territory. Like the ICM Congress, the goal of this national meeting is to provide an important forum for the organization to conduct its national business, to provide an important opportunity for networking amongst midwives and to provide a conference program that covers important areas of midwifery practice, education, and research.

8.11.3 Canadian Midwifery Regulators Council (CMRC)

The CMRC was formed in 2000 and is comprised of all the provincial and territorial midwifery regulatory authorities in Canada. It was originally created in order to develop a national process that would facilitate the recognition and mobility of midwife registration across jurisdictions thereby facilitating mobility of the midwifery workforce throughout Canada. The CMRC’s mandate has evolved over the years to include a number of other aspects to support protection of the public interest in its member jurisdictions, including setting and maintaining high national standards of midwifery practice and developing common administrative processes between the colleges and regulatory bodies.

A contribution of the CMRC has been development of the Canadian Midwifery Competencies. This document outlines the knowledge and skills expected of an entry-level midwife in Canada. They were developed in a collaborative effort involving all the provinces and territories, and they maintain consistency of practice across the country. In addition, the CMRE is based on the Canadian Midwifery Competencies and is administered by the CMRC. The CMRC has produced a number of important position statements including:

• CMRC Diversity Statement (2011)
  http://cmrc-ccosf.ca/sites/default/files/pdf/CMRC_Diversity_Statement_Final_2011.pdf
• CMRC Ethical Recruiting Statement (2011)
  http://cmrc-ccosf.ca/sites/default/files/pdf/CMRC_Ethical_Recruiting_Statement_Final_2011.pdf
• CMRC Position Statement on the Use of Gender Inclusive Language (2016)
  http://cmrc-ccosf.ca/sites/default/files/pdf/Gender%20Inclusivity%20Statement%20FINAL%20EN%20April%202016.pdf
• CMRC Position Statement on the Protected Title of “Midwife” (2016)
  http://cmrc-ccosf.ca/sites/default/files/pdf/Use%20of%20Protected%20Title%20of%20Midwife%20Statement%20FINAL%20EN%20April%202016.pdf

Since 2009, a representative of the CMRC has been a member of the ICM Regulation Standing Committee (representing the Americas) and participated in the development of the ICM’s Global Standards for Regulation.

8.11.4 National Aboriginal Council of Canada (NACM)

Midwives have always formed a part of Aboriginal communities in Canada but the practice of Aboriginal midwives in their local communities has changed over time and is emerging as an important feature of maternity care in those communities. (2) The National Aboriginal Council of Canada (NACM) was formed in 2008 in response to a need to support the development of midwifery in Aboriginal communities and to provide support for Aboriginal midwives. Its vision is “Aboriginal midwives working in every Aboriginal Community”. The mission of NACM includes advocating for the restoration of midwifery education, the provision of midwifery services and the choice of birthplace for all Aboriginal communities consistent with the U.N. Declaration on the Rights of Indigenous Peoples. NACM functions as an umbrella organization within the Canadian Association of Midwives and its membership includes midwives from across Canada representing First Nations, Inuit and Métis midwives.

8.5 Key Points

• The organization and regulation of midwifery varies throughout the world. In some countries, it is regulated by health profession acts and regulatory bodies (colleges). The ICM values this means of regulation as a way to improve the standards of maternity care.
• In Canada, regulation of midwifery began in the 1990s when midwifery care in Ontario was integrated into the funded health services. Regulation of midwifery and Aboriginal midwifery in Canada varies by province/territory, but generally identify midwives as autonomous health care professionals with a defined scope of practice that includes providing maternity care to healthy clients and newborns up to six weeks postpartum.
• In Canada, midwifery is a self-regulating profession, which means that members of the profession are responsible for ensuring that midwifery legislation is enforced, effectively. Regulatory bodies, often called colleges, develop codes of ethics, standards of practice, and policies for midwifery.
• Practicing midwives must understand the codes of ethics, and maintain professional integrity and boundaries. There may be several standards to which a midwife is held accountable. These include the standards identified by their college/regulatory authority, their employer/practice, and any applicable national laws on health information confidentiality.
• The ICM is an accredited non-governmental organization that provides leadership and standards for midwifery for 108 member countries.

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